EMOTIONAL EATING SCALE FOR CHILDREN AND ADOLESCENTS. PSYCHOMETRIC CHARACTERISTICS IN A SPANISH SAMPLE
Conxa Perpiñá a,b, Ausiàs Cebolla b,c, Cristina Botella b,c; Empar Lurbe c,d, María Isabel Torró c,d
a) University of Valencia. Departamento de Personalidad, Evaluación y Tratamientos Psicológicos, Faculty of Psychology, University of Valencia, Avda. Blasco Ibáñez 21, 46010 Valencia, Spain b) Ciber Fisiopatología Obesidad y Nutrición (CIBEROBN), Instituto Salud Carlos III; Spain c) University Jaume I (UJI), Castellón, Spain d) Child & Adolescent Cardiovascular Risk Unit. Pediatric Service. University General Hospital. Valencia. Spain
Corresponding author. Tel.: +34 963 983 494 fax: +34 963 864 476. E-mail address:
[email protected] (Conxa Perpiñá). Departamento de Personalidad, Evaluación y Tratamientos Psicológicos, Facultad de Psicología Avda. Blasco Ibáñez, 21 46010 – Valencia
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Abstract
The main objective of this study was to validate the Emotional Eating Scale version for children (EES-C) in a Spanish population and study the differences in emotional eating among children with binge eating (BE) overeating (OE), and no episodes of disordered eating (NED). The questionnaire was administered to 199 children between the ages of 9 and 16 years, from primary and secondary schools. Confirmatory Factor Analysis revealed five scales: eating in response to anger, anxiety, restlessness, helplessness and depression. The scale showed good internal consistency and test–retest reliability, and it showed moderate relationships with measures of Eating Disorders (ChEAT-26, QEWP-C) and psychopathology (STAI-C, CDI, CBCL). There were significant differences between the BE and NED groups (with the OE group in the middle position) in desire to eat when Anger (the girls in BE group, and the oldest children in OE group obtaining higher scores) or Helplessness were present. Eating due to Depression was higher in the older groups. A multiple regression analysis conducted using Emotional Eating as a predictor showed that anxiety-trait is the best predictor. Results support the potential utility of the EES-C in the study of emotional eating in children, and its validity in the Spanish population.
Keywords Emotional Eating, Binge Eating Disorder, children psychopathology, Loss of Control, Psychometric properties
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Introduction Emotional Eating (EE) has been defined by Faith, Allison, and Geliebter (1997) as eating in response to a range of negative emotions, such as anxiety, depression, anger and loneliness, to cope with negative affect. It has been outlined as a coping style related to diffuse negative emotions, but positive emotions are also reported (Van Strien, Herman & Verheijden, 2009). Eating in response to negative emotions is reportedly common among children (Tanofsky-Kraff et al., 2007), especially those who are obese (Shapiro et al., 2007), and it has been linked to loss of control eating (Shapiro et al., 2007; Tanofsky-Kraff et al., 2007). There is growing evidence that binge- and over- eating frequently occur in the absence of other eating disorder diagnoses, and they can best be contemplated as lying along a continuum from normal to disordered eating (Blackburn, Johnston, Blampied, Popp & Kallen, 2006). Problems with emotion management and regulation are associated with psychopathologies, and they are assumed to play an important role in the initiation and maintenance of binge eating. Moreover, children with symptoms of binge eating engage in eating in response to negative affect (Czaja, Rief, & Hilbert, 2009). The Binge Eating Diagnosis (BED), as defined in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) (APA, 2000), includes recurrent episodes of binge eating during which subjective sense of loss of control (LOC) episodes occur that are often reported as triggered by dysphoric moods, such as depression and anxiety. Furthermore, impulsive behaviors appear to be a transdiagnostic characteristic in Eating Disorder (ED) patients, not being uncommon among other ED clinical subtypes (Favaro et al., 2005). Although the relationships among disordered eating, impulsivity and difficulties in emotional regulation have been extensively studied in adults, it is still unclear whether binge eating in children is associated with deficits in emotion regulation, and which
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emotion regulation strategies are problematic. Therefore, instruments that evaluate the vulnerability and risk factors of overeating and binge eating, such as emotional eating, are quite useful. The Dutch Eating Behavior Questionnaire (DEBQ; Van Strien, Fritjers, Bergers, & Defares, 1986) assesses restrained and external, but emotional, eating; however, it does not differentiate between various types of emotions. In order to facilitate investigation of the relationship between specific negative emotional states and overeating, Arnow, Kenardy, and Agras (1995) designed the Emotional Eating Scale (EES), a 25-item self-report measure scored on a 5-point Likert scale (from “no desire to eat” to “an overwhelming desire to eat”), that assesses the extent to which an individual eats in response to emotions. The EES consists of three subscales reflecting the urge to eat in response to: anger/frustration, anxiety, and depression. It was initially administered to 47 obese females with binge eating symptoms, demonstrating a strong internal consistency for the entire scale ranging from .81 (Arnow et al., 1995) to 0.93 (Waller & Osman,1998), and for each subscale: anger/frustration, anxiety, and depression (coefficient alphas, .78, .78, and .72, respectively). More recently, the EES was adapted for Children and Adolescents (EES-C) (Tanofsky-Kraff et al., 2007), for use with 8-17 year old children. Some modifications were made in the vocabulary of the EES in order to make it more accessible to children. The term “happy” was added to the original list of emotions, and a column was incorporated asking about the number of days per week the children ate in response to each emotion. The adapted instrument was completed by 205 children. Thus, the EES-C is a 25-item self-report measure used to assess the urge to cope with negative affect by eating, and it generates three subscales: depression, anger/anxiety/frustration, and feeling unsettled. Respondents rate their desire to eat in response to each emotion on a 5-point scale (No desire, Some
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desire, Moderate desire, Strong desire, and Very strong desire to eat). Higher scores indicate a greater reported desire to eat in response to negative mood states. The EES-C subscales have demonstrated very good internal consistency (alphas: from 0.83 to 0.95), convergent validity, and adequate temporal stability (Tanofsky-Kraff et al., 2007). The main aim of the present study was to validate the Emotional Eating Scale for children and adolescents (EES-C) (Tanofsky-Kraff et al., 2007) in the Spanish population and analyze its psychometric properties. Other objectives were to analyze the differences in emotional eating according to gender, age, weight and LOC, and study which variables predict the emotional eating, differentiating each emotion, in pre-adolescent participants.
Method Participants Children and adolescents aged 9-16 years were recruited. The clinical group consisted of 71 participants seeking weight loss treatment in the Pediatric Unit at the General Hospital (Valencia, Spain). The non clinical group (n=128) was recruited from two elementary schools in the city of Valencia. The children provided written assent, and the parents gave written consent for participation in the protocol. These studies were approved by the Ethical Committee from the General Hospital and by the respective local school boards.
Measures Children's heights were measured by a calibrated electronic stadiometer TANITA BC 418 MA (Holtain, Crymych, Wales), and their weights were measured to the nearest 0.1 kg by a calibrated digital scale (Scale-Tronix, Wheaton, IL). Body Mass Index standard deviation scores (BMI-Z) were calculated. Obesity was
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calculated with a z-score adjusted for sex and age. The subjects were classified as obese (over 95th percentile) or overweight (between 85th-95th percentiles) with a zscore above 2.0, and as normal weight with a z-score of less than 1.0 (Weiss, Dziura et al., 2004). Given that this classification is based on North American data, the normative data for the Spanish population were used as the correction factor (Sobradillo et al., 1988). The Emotional Eating scale adapted for children and adolescents (EES-C; Tanofsky-Kraff et al., 2007), designed for use with 8–17 year old children, is a 25item self-report questionnaire scored on a 5-point Likert scale (no desire to eat very strong desire to eat) used to assess the urge to eat in order to cope with negative affect. The psychometric properties of this English-language instrument are described above. In order to adapt and validate the Spanish version, the EES-C was translated by the first author (forward translation) and then revised by a bilingual psychologist from the USA (backward translation). The discrepancies between the two translations were resolved by a professional English translator. The Children's Depression Inventory (CDI; Kovacs, 1985). It consists of 27 Likert-type items ranging from 0 to 2 (0 indicating an absence of symptoms, 1 indicating mild symptoms, and 2 indicating definite symptoms), which assess depressive symptomatology in children. A score ≥ 19 is the criterion score for identifying clinical depression. The Spanish adaptation was used in this study (Del Barrio & Carrasco, 2004). The internal consistency of the CDI in the current sample was α=.82 for the one factor solution, for self-esteem α=.67, and for dysphoria α=.80. The State-Trait Anxiety Inventory for Children (STAIC; Spielberger, Edwards, Lushene, Montuori, & Platzek, 1973). This scale was developed to measure trait and state anxiety symptoms in children. For the analyses in the present study, we used only the trait scale, composed of 20-items, with a 3-point scale ranging from 1
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(almost never) to 3 (often). The scale was validated in a Spanish sample for children from 9 to 15 years of age (Seisdedos, 1990). The internal consistency of the STAIC in the current sample was α=.88. The Child Behavior Checklist for ages 4–18 (CBCL; Achenbach, 1991). The CBCL, generally accepted as an objective tool for screening symptoms of psychopathology, is a parent-reported measure of child competency and functioning in a range of behavioral domains. This 138-item rating scale yields scores for total behavior problems, internalizing and externalizing behaviors, and three scores for competence (activity, social competence, school competence). Parents rate their child on how true each item is now or within the past 6 months using the following scale: 0 = not true (as far as you know); 1 = somewhat or sometimes true; 2 = very true or often true. The CBCL generates eight clinical subscales grouped in two scales, the Internalizing scale (Withdrawn, Somatic Complaints, and Anxious/Depressed mood) and the Externalizing scale (Disruptive and Aggressive Behavior). The Spanish validated version (Albores et al., 2007) was used, with an internal consistency in the current sample ranging from .90 to .97. The Children’s Eating Attitudes Test (ChEAT; Maloney, McGuire, & Daniels, 1988) is a self-report questionnaire used to assess disordered eating attitudes among children. Each item is rated on a Likert scale from 1 (always) to 6 (never). This scale is a children’s version of the Eating Attitude Test (EAT; Garner, Olmsted, Bohr & Garfinkel, 1982). In this study, the Spanish adaptation containing 20 items (Sancho, Asorey, Arija & Canals, 2005) was used. This version of the ChEAT generates four factors: fear of and preoccupation with getting fat, social pressure to eat, food preoccupation and food restriction. The internal consistency of the ChEAT in the current sample was α=.79. With regard to each factor, for Fear of and Preoccupation with getting fat α=.71, for Social pressure to eat α=.71, for Food preoccupation α=.53, and for Food restriction α=.65.
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The Questionnaire of Eating and Weight Patterns - Adolescent Version (QEWP-A; Johnson, Grieve, Adams, & Sandy, 1999; Johnson, Kirk & Reed, 2001). Responses to this questionnaire classify children and adolescents as: those reporting overeating (OE); those reporting binge eating behavior (BE), that is, overeating experiencing LOC, thus measuring objective binge episodes; and those reporting no episodes of disordered eating (NED), within the past six months. The QEWP-A appears to have adequate concurrent validity when correlated with measures of abnormal eating attitudes and depression (Johnson et al., 1999).
Procedure The clinical group completed all measures during an outpatient clinic visit to the Hospital. The non clinical group filled out the questionnaires during their normal school day. For all the children, in cases where they had difficulty reading or understanding the questions, trained research assistants read the questions aloud and provided simple alternative definitions for words and statements that were not understood. In order to study the temporal stability, the EES-C was administered to 40% of the original sample 1-2 months later.
Statistical Analysis Confirmatory factor analyses were conducted using the EQS 6.1 program (Bentler, 1995). Maximum Likelihood estimates with robust corrections were obtained in order to deal with violations of the normal distribution assumption. Assessment of model fit was performed using the goodness-of-fit χ2 test statistic. Another index used to assess the adequacy of each model was the comparative fit index (CFI), which compares the fit of the model to a null model and establishes the absence of relationships among the variables. Other indexes used were the GFI and AGFI fit indexes, which measure the proportion of variance-covariance
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accounted for by the proposed model. The standardized root mean square residual (SRMS) and the root mean squared error of approximation (RMSEA) penalize the models that are not parsimonious, and they are sensitive to misspecified factor covariance. Internal consistency (Cronbach's α's), and the interclass correlation coefficient (ICC) were calculated in order to establish the reliability. Convergent and divergent validity analyses were conducted by computing Pearson’s correlations. To assess group differences, Chi-square tests and ANOVAs were computed using F or BrownForsythe depending on the homogeneity of the samples. Tukey or Games-Howell post-hoc statistics were applied to examine the source of between-groups differences. Finally, multiple regression analyses (stepwise) were used to examine relationships between the EES-C subscales, taking into account each emotion independently as the dependent variable and the rest of the relevant variables (sex, age, weight and psychopathology measures) as independent variables. Associations and differences were considered significant when p values were ≤0.05. All analyses were conducted using SPSS for Windows, 15.0 (SPSS, Inc., Chicago, IL).
Results A total of 199 children (clinical and non clinical samples) (Mean age: 12.7±2.0 years, range: 8-17; 50.2% girls) participated in this study (Table 1). The entire clinical group (n=71) was obese/overweight (BMIZ>85-95th percentile). The non clinical sample was composed of 84 normal weight (BMI-z< 85th percentile) and 44 overweight/obese children (BMIZ>85-95th percentile). Thus, 115 (57.7%) were overweight/obese. Parents provided data about economic status. Table 1 shows the socio-demographic data of the participants.
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Insert table 1
Descriptive analysis of the items Of the 26 items listed on the EES-C, the children most commonly endorsed eating in response to feeling “bored” (66%), while feeling ”excited” (53.3%) and “worn out” (51.8%) were the second and third most common emotions reported, respectively (see Table 2). If we focus on the mean of the emotion that most often unleashes the eating response, it is again “bored”, followed by “excited”, although there was a large amount of response variability. Finally, if we take into account the frequency of days per week, the emotion that most frequently led to eating was “happy”, followed by “bored” and “lonely”. In contrast, the highest percentage of the sample who never had the desire to eat were acting in response to feeling “resentful” (82.1%), followed by “disobedient” (81.0%) and “furious” (77.9%).
Insert table 2
Confirmatory Analysis Four models of the Emotional Eating Scale (excluding the adjective “happy” for these analyses) were selected to be compared on adequacy fit. Table 3 shows the items for each model. Model 1 tested a single-factor model composed of only one factor structure that included all the EES-C items. This model is used as a baseline model against which to test alternative factorial structures. Model 2 corresponds to the original factorization by Arnow et a.l, (1995) of the Emotional Eating Scale. The first factor in Arnow’s model consists of emotions related to anger, the second to anxiety, and the third to depression. The third model is a structure of three factors (anxiety, depression and unspecified factor) developed in the original children’s version of the EES created by Tanofsky-Kraff et al., (2007).
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The fourth model is the result of a previous exploratory factor analysis that yielded a five-factor model consisting of Anger, Anxiety, Depression, Restlessness and Helplessness.
Insert table 3
The four models were compared with regard to their adequacy of fit using Hu and Bentler’s (1995, 1999) recommended approach to fit criteria; a small χ2 of a model means better fit to the data. The other criteria indices for goodness of fit used were: CFI >.90, GFI and AGFI >.90, SRMS
